R-4062 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Ras 4062
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
. BUILDING ADDRESS - BUILDING USE
�7�� RESIDENTIAL COMMERCIAL OTHER
OWNERIS
HAZARDOUS _ l ROOF
NAME FIRE 14/1 COVERING
AREA ���VVV CLASS
ADDRESS EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S f 1
y /! TO BE REMOVED TO BE RETAINED
NAME 7 �-!T TYPE OF ROOF COVERING
ADDRESS D
CITY&zip f . �1 �f 0 EXISTING
L I Lif!( gfoba BUILT-UP ROOF
PHONE /
LICENSE 7th 38S ASPHALT SHINGLES
NUMBER ! J
WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
I hereby eftirm 7000 1•m licensed 3 of t provisions of Chapter onslcommenCode
cine with Section 70001 or Divieon 3 of cite Business end robnlom Coda WOOD SHINGLE
and my license is I yll and affect.
License Ciro Lic.Number
Date Connector OTHER (SPE YI
O NER-BUILDER DECLARAT
I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED - C^/
the following reason. (Sec. 7031.6, Business and Professions Coda: Any city �'1 J
or county which r•quim a permit t0 construct, altar, Improv, damolisn,or
repair anv structure,prior to its issuance,also requires the applicant for such BUILT-UP OOF
permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter 9 (commencing with Section 7000) p.
of Division 3 of the Business end Profession.Coital or met he is exempt there' ASPHALT SH GLES
•
from and the basis for the alleged exemption. Any violation of Section
7031.5 by am applicant for•Permit subjects the applicant to a civil penalty
of not more that five hundred dollars($500).1: WOOD SHAKES
❑ I,as owner of the property, or my employees with wages as their tole I
compensation,will do the work. and the structure is not intended or offered WOOD SHINGLES !.
for Sale(Sec. 7044, Business and Professions Code: The Contractors License F
Law dose not apply b an own.,of property who tit"Id%or improves thereon.
and who does such work himself or through his own employees,Provided that
�Q
Such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
builds np or improvement is sold within one year of completion, the o
builder will neve me burden of proving that he did not build Or improve nfor
purpose of Sale,). PROVIDE I.C.B.0 REPOR NO.
❑ I. as owner of the properly. . exclusively contracting with licensed
contractors to construct tM1e proi act (Sec. 7044, Business and Professions
Coda: The Contractor's Li cense Law does not apply to an owner Of property PROVIDE MFGR. INSTALLATION SPECS.
who builds o mprove$ thereun, and who convects for such projects with e
contractor(s)licensed pursuant to the Contractors License Law.
❑ 1 am exempt under Sac. ,B.$,P.C.for this
reason PP,L•fC.TION DATE VALUATION PERMIT FEE
Owner Date sy P�
WORKERS'COMPENSATION DECLARATION G BuildingTA -to
1 nareby eftirm that I have a certificate of consent to self insure,or a ser
tificeta of Workers Compensation Insurance,or a certified copy thereof(Sac./� D Seismic
3800,Lab.C.I. C1 O
Policy No. Company �/y�
CotiNed copy is hereby furnished. L' 9S ��y Total
Certified copy is filed with the city inspection division,
~C IJL�
Applicant K
CERTIFICATE OF EXEMPTIONFROM WORKERS' N C, CERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(Thio section nobe ccund not be Completed it the permit is for one hundred dote ® /�
($
Are 1D0)or tyr
1 certify test hat In m• performance of mthis work for which ia permit is
n C/
sued, 1 shall not employ any person in any men er so as to become subject
to the Workers Compensation Laws of California.
DabApplicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you mould become subject to the Workers Compensation provisions of the
Labor Code. you must forthwith comply with such provisions or this permit All roofsshall be inspected prior to any roofing material being
mall be deemed reeoked.
1 Certify mat l nava read this application and state that the above inform. installed. If a roof is Installed without first obtaining an
eon i. correct. I eoru to g cons with eta city and county ori. r.,, an a ins action,I agree to remove all new m�i sfor inspection
Site Issue relating to building Commotion, nti hereby author
for
tepresen
Tr
tabus of this city to enter upon tN above mentioned property for Impaction
purposes. JIEe�Ii/1�-v'-_AYA_'s`1IfL
(We) agree to save, indemnify and keep harmless the City of Cupertino
again.:liabilities,judgments.costs and expanses which
.wins:said City in consequence of the granting of this permit.any way.terse $IG A URE F APP CANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL,
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY